Provider Demographics
NPI:1578063582
Name:CHILTON, RAESHUN (LVN)
Entity Type:Individual
Prefix:MRS
First Name:RAESHUN
Middle Name:
Last Name:CHILTON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4264 FORBES ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-5017
Mailing Address - Country:US
Mailing Address - Phone:682-201-8205
Mailing Address - Fax:
Practice Address - Street 1:13601 PRESTON RD STE 210W
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-4986
Practice Address - Country:US
Practice Address - Phone:903-532-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX308755164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX01052626OtherDRIVERS LICENSE